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IrxlutrkrpServx=DivWon county U�',1i <br /> 1400 E Wad ingion /J <br /> P.O.Box 7162 umber(b be Del w by Co.) <br /> Madison,W133707-7162 39 <br /> OAT- _ ` 3-5 <br /> State Transaction Number <br /> Sanitary Permit Application Vt <br /> in accadantx with SPS 39311(2),Wit Ada-Code,submission of this form to the appropriate gcrvammmW unit IV <br /> isreWif edprior to obUWWg a sanitmy permit Nose:Appbcstm forces for sta tao mOd PO9VTS are submitted to P%tect Address(if dFaud than Mad ing address) <br /> the Deparaneatof Srfo y and Proftessarial Services.Persord infomnatian you provide mry be used for secondary <br /> . with tl►a � later a 15. l m Stds- !" <br /> i. tit�rrtrtat m-Plows PrUt AN Infer vald w l'c:nJivc;�s LAKE 6'�0! / <br /> Property OwwsNaae c Parrd M 0'7-of <br /> M F Sr 03-0a) oil 6 f <br /> Property Owners Mailing Address Property Location <br /> 55z Ve : coot.Nat <br /> City,Stab Zip Code Phone S Syr y., �ti`V, Section vim' <br /> •G��� CJ�o�� !1NV � / T,.�1.— <br /> II.Type of lbaildiiag(cheek all riot apply) lot rt <br /> -� --� Subdivision Heine <br /> I or Foa-ty Dwelling-Number of Bedrooms 3 <br /> Bb&# AM- <br /> 0 -Dambe Use 0 City of <br /> 0 State OmW-Dt wft Use CSM Number ❑Village of <br /> 3 <br /> 1 Town of <br /> IIL 1pps«f Permft (Check only am box err Ow A. Complae lire B N appiiea lt) <br /> A- j4N.System 0 Replao..*System 0'1 rcooer Jt odding T.&Roj,.�Only ❑Oerer Modifi.W.m EXWrq Syataa( ) <br /> B. ❑permit R,erbwal 0 PerrndPXV s M ❑(2mw o(Ph mbw Q PcMit'=s*r so New List Previous Permit Number and Doc hued <br /> Bekn lboraion Owner <br /> IV Tmw OfPOW'TS S Cbeek all that <br /> IVaa`Ppmu,risea rn-t tnad 0 PtessMaed ltrGtound ❑At Grade 0 Mouod>2a iL otmablC 30d 0 Mound<2a ice.of suWbk soil <br /> OHOWMBTwk jI°&ff D CMPw(.,pbi.) Fl1-rr 6,KN' 0 Awcauncra Device(explain)_ <br /> V. Area Iaforta OM- <br /> Desia Flow(mod) t ksW Soil Applicafim Ro*Wdsf) Dispersal Area Required(sf) Disp«sel Area Proposed(sf) Syst�r• <br /> VI.Tank We Capacity in Total 8 of Manufacturer � <br /> Gd M Gallons Units <br /> Nm TsWa E%iw i%T=kI I�I <br /> i G� / OTC 1Nr�t_7t� C�G. <br /> sVdI- <br /> V1t. $taftwomt-I,tie Ur tadagtlian of We Pow"sh"M so tie attxeid ptaq <br /> Pluunbet•'s N®e(prim) Phmtbar' - <br /> eopw -T-IA- a MONVA-Number II3aaiotmPfuooaManber <br /> PIuwbw'a Aadrm(Street,city,StatS zip C«!t) $24 33 <br /> 93©b 'ver, BROOK R-'C" wasnE7g w.x s-q Sq3 <br /> VUr. 11 Vat <br /> Apt 0 Disapproved Permit Fa ,te)sa lasting Agent Si <br /> S <br /> 0 Owoer Given Reason for Denial <br /> rx.Caalifisas of AppravaUReawaa for Dl"p— <br /> wr.ry a arrgrLw Mt...r r�,�.�r.r►.`rr r pr CO w'..*y 0.l4�Mr yea air.a <br /> s <br /> SM-63"A W14) MAY 18 2021 <br /> umett County <br /> Land Services Department <br /> �3 <br />